The Effectiveness of Disease and Case Management
for People with Diabetes
A Systematic Review
Susan L. Norris, MD, MPH, Phyllis J. Nichols, MPH, Carl J. Caspersen, PhD, MPH, Russell E. Glasgow, PhD,
Michael M. Engelgau, MD, MSc, Leonard Jack Jr, PhD, MSc, George Isham, MD, Susan R. Snyder, PhD,
Vilma G. Carande-Kulis, PhD, Sanford Garfield, PhD, Peter Briss, MD, David McCulloch, MD, and the Task
Force on Community Preventive Services
Overview:
This report presents the results of a systematic review of the effectiveness and economic
efficiency of disease management and case management for people with diabetes and
forms the basis for recommendations by the Task Force on Community Preventive Services
on the use of these two interventions. Evidence supports the effectiveness of disease
management on glycemic control; on screening for diabetic retinopathy, foot lesions and
peripheral neuropathy, and proteinuria; and on the monitoring of lipid concentrations.
This evidence is applicable to adults with diabetes in managed care organizations and
community clinics in the United States and Europe. Case management is effective in
improving both glycemic control and provider monitoring of glycemic control. This
evidence is applicable primarily in the U.S. managed care setting for adults with type 2
diabetes. Case management is effective both when delivered in conjunction with disease
management and when delivered with one or more additional educational, reminder, or
support interventions.
Medical Subject Headings (MeSH): community health services, diabetes mellitus, evidencebased medicine, preventive health services, public health practice, review literature (Am J
Prev Med 2002;22(4S):15–38) © 2002 American Journal of Preventive Medicine
Introduction
D
iabetes mellitus (diabetes) is a prevalent, costly
condition that causes significant morbidity and
mortality. In the United States, 15.7 million
people (5.9% of the total population) have diabetes, of
whom 5.4 million are undiagnosed.1 In 1997 alone,
789,000 new cases were diagnosed.1 Moreover, according to death certificate data, diabetes is the seventh
leading cause of death in the United States.1 Mortality
is primarily related to heart disease: adults with diabetes
have death rates from heart disease about 2 to 4 times
higher than those without diabetes.1 In addition, the
risk of stroke is 2 to 4 times higher in people with
diabetes. Diabetes is the leading cause of new cases of
From the Division of Diabetes Translation, National Center for
Chronic Disease Prevention and Health Promotion (Norris, Nichols,
Caspersen, Engelau, Jack), and Epidemiology Program Office (Snyder, Carande-Kulis, Briss), Centers for Disease Control and Prevention, Atlanta, Georgia; AMC Cancer Research Center (Glasgow),
Denver, Colorado; HealthPartners (Isham), Minneapolis, Minnesota;
Diabetes Program Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (Garfield),
Bethesda, Maryland; and Group Health Cooperative of Puget Sound
(McCulloch), Seattle, Washington
Address correspondence and reprint requests to: Susan L. Norris,
MD, MPH, Centers for Disease Control and Prevention, MS K-10,
4770 Buford Highway NE, Atlanta, GA 30341. E-mail: Scn5@cdc.gov.
blindness in adults aged 20 to 74 years, and it is also the
leading cause of end-stage renal disease, accounting for
about 40% of new cases. Neuropathy is also a major
problem, as 60% to 70% of people with diabetes have
this condition, and more than half of lower limb
amputations occur among people with diabetes. Finally, the rate of pregnancies resulting in death of the
newborn is twice as high among women with diabetes
than among those without this disorder.1
Consistent with its extraordinary effect on the health
of Americans, the costs of diabetes to the U.S. healthcare system are enormous: total (direct and indirect)
costs were estimated at $98 billion in 1997.2 Selby et al.3
calculated that per-person expenditures for members
of a managed care organization with diabetes were 2.4
times higher than for those without diabetes. Thirtyeight percent of the total excess costs was spent on
treating long-term complications, particularly coronary
heart disease.
Traditionally, healthcare delivery involves individual
providers reacting to patient-initiated complaints and
visits. Care is frequently fragmented, disorganized, duplicative, and focused on managing established disease
and complications. Providers practice what they have
been taught and what their anecdotal experiences have
Am J Prev Med 2002;22(4S)
0749-3797/02/$–see front matter
© 2002 American Journal of Preventive Medicine • Published by Elsevier Science Inc.
PII S0746-3797(02)00423-3
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led them to believe is effective. The goals are generally
short term, such as pain control or avoidance of
hospital admission. Management is provider-directed
and focuses on pharmacologic and technologic interventions, with little attention to patient self-management behaviors or provider–patient interactions.4
Traditional methods of healthcare delivery do not
adequately address the needs of individual people or
populations with diabetes. For example, in a survey of
the care received by patients of primary care providers,
people with diabetes were receiving only 64% to 74% of
the services recommended by the American Diabetes
Association (ADA) Provider Recognition Program.5
And in a chart audit covering 1 year in a health
maintenance organization (HMO) setting, glycated hemoglobin (GHb)a values were documented for only
44% of people with diabetes (ADA recommends two to
four measurements per year), and annual urine protein
measurements were performed on only 48% of patients.6
Available evidence shows that improving care for
people with diabetes results in cost savings for healthcare organizations. In a review of economic analyses of
interventions for diabetes, eye care and preconception
care were found to be cost saving, and preventing
neuropathy in type 1b diabetes and improving glycemic
control with either type 1 or type 2 diabetes were found
to be clearly cost-effective.7 Gilmer et al.8 modeled cost
savings at an HMO and found that every percentage
point increase in hemoglobin A1c (HbA1c) above
normal was associated with a significant increase in
costs over the next 3 years. Testa et al.9 noted that
improved glycemic control was associated with shortterm decreases in healthcare utilization, increased productivity, and enhanced quality of life. Wagner et al.10
found that a sustained reduction in HbA1c was associated with cost savings among adults with diabetes within
1 to 2 years of improved glycemic control.
In the last decade, innovative interventions for
healthcare delivery have emerged that show promise
for improving care, outcomes, and costs for individuals
and populations with diabetes. Disease and case management are two such new interventions. This review
examines the extent and quality of the evidence of their
effectiveness when applied to people with diabetes.
a
GHb (including hemoglobin A1c [HbA1c]) describes a series of
hemoglobin components formed from hemoglobin and glucose, and
the blood level reflects glucose levels over the past 120 days (the life
span of the red blood cell).
b
Type 1 diabetes, previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes, accounts for 5% to 10% of all
diagnosed cases of diabetes and is believed to have an autoimmune
and genetic basis. Type 2 diabetes was previously called non–insulindependent diabetes mellitus (NIDDM) or adult-onset diabetes. Risk
factors for type 2 include obesity, family history, history of gestational
diabetes, impaired glucose tolerance, physical inactivity, and race/
ethnicity. (Source: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention. National diabetes fact
sheet. 1998. Available at: www.cdc.gov/diabetes/pubs/facts98.htm.
Accessed January 10, 2002.)
16
The Guide to Community Preventive Services
The systematic reviews in this report represent the work
of the independent, nonfederal Task Force on Community Preventive Services (the Task Force). The Task
Force is developing the Guide to Community Preventive
Services (the Community Guide) with the support of the
U.S. Department of Health and Human Services
(DHHS) and in collaboration with public and private
partners. The Centers for Disease Control and Prevention (CDC) provides staff support to the Task Force to
develop the Community Guide. A special supplement to
the American Journal of Preventive Medicine, “Introducing
the Guide to Community Preventive Services: Methods, First
Recommendations and Expert Commentary,” published in January 2000,11 presents the background and
the methods used to develop the Community Guide.
Evidence reviews and recommendations have been
published previously on vaccine-preventable diseases,12–14 tobacco use prevention and control,15–17 and
motor vehicle occupant injury.18,19
The Community Guide addresses many of the diabetesrelated objectives of Healthy People 2010, the prevention
agenda for the United States.20 Objectives 5-11 through
5-15 relate to improving screening for complications
involving the kidney, retina, extremities, and the oral
cavity and monitoring of glycemic control.20 By implementing interventions shown to be effective, healthcare
providers and administrators can help their organizations achieve these goals while using resources efficiently. This report, in combination with the accompanying recommendations,21 provides information on
interventions that can help communities and healthcare systems reach Healthy People 2010 objectives.
Methods
The Community Guide’s methods for conducting systematic
reviews and linking evidence to effectiveness are described
elsewhere.22,23 In brief, for each Community Guide topic, a
systematic review development team representing diverse
disciplines, backgrounds, and work settings conducts a review by
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developing an approach to identifying, organizing, grouping, and selecting interventions for review;
developing an analytic framework depicting interrelationships between interventions, populations, and outcomes;
systematically searching for and retrieving evidence;
assessing and summarizing the quality and strength of the
body of evidence of effectiveness;
translating evidence of effectiveness into recommendations;
summarizing data about applicability, economic and other
effects, and barriers to implementation; and
identifying and summarizing research gaps.
The diabetes systematic review development team (see
author list) generated a comprehensive list of strategies and
created a priority list of interventions for review based on the
(1) importance of the intervention in decreasing morbidity
and mortality and in improving quality of life for people with
American Journal of Preventive Medicine, Volume 22, Number 4S
Figure 1. Analytic framework for disease and case management. Ovals denote interventions, rectangles with rounded corners
denote short-term outcomes, and rectangles with squared corners denote long-term outcomes.
BP, blood pressure; PA, physical activity; SMBG, self-monitoring of blood glucose.
diabetes, (2) potential cost-effectiveness of the intervention,
(3) uncertainty about the effectiveness of the intervention,
and (4) potential feasibility of implementing the intervention
in routine public health practice. Two priority areas were
selected for review. The systematic review on the effectiveness
of diabetes self-management education interventions in community settings is found in the accompanying article.24 In this
review we focus on two healthcare system interventions:
disease management and case management.
The analytic framework for disease and case management
interventions (Figure 1) illustrates our conceptual approach
and depicts the relationships between interventions and
provider and patient outcomes. The multifactorial nature of
disease management is demonstrated by listing the subelements under the main elements of healthcare delivery system,
providers, patients, and populations. Case management can
be implemented along with disease management, as a single
intervention, or with other interventions. It is, therefore,
depicted as overlapping with disease management in Figure 1.
Outcomes for disease and case management also involve
the healthcare system, provider, and patient or population
(Table 1). Evidence for all outcomes listed was examined in
these reviews, but the recommendations of the Task Force21
were based on a subset of the outcomes thought to be most
related to health and quality of life (those outcomes are in
bold in Table 1). The healthcare system’s structure, processes, and resources affect the knowledge, attitudes, and
behaviors of providers, particularly with respect to screening
for complications and prevention and treatment practices.
Provider monitoring and subsequent appropriate management of GHb, blood pressure, and lipid levels can be associated with improved outcomes, as these physiologic measures
are related to health outcomes25–29, and effective treatments
and prevention strategies are available.29 –32 Annual screening for retinopathy, nephropathy, and foot lesions and peripheral neuropathy, followed by appropriate management
for people identified with abnormalities, is associated with
improved health outcomes in people with diabetes.30,33–37
Disease and case management can affect patient knowledge38 and psychosocial mediators such as self-efficacy,39
social support,40 and health beliefs,40,41 which, in turn,
predict self-care behaviors. Patient self-care behaviors (e.g.,
self-monitoring of blood glucose) and lifestyle correlate with
short-term outcomes (glycemic control, blood pressure, lipid
concentrations, renal function, lesions of the feet, and diabetic retinopathy),25,37,42– 48 which, in turn, affect long-term
health (microvascular and macrovascular disease), quality of
life, and mortality.25–28,31,49
The Community Guide focuses on interventions in community settings, interventions involving populations, and healthcare system approaches to care. Our consultants (see Acknowledgments) judged disease and case management to be
important healthcare system-level interventions for people
with diabetes. Our review did not examine evidence of the
effectiveness of clinical care interventions focused on the
individual patient: recommendations on clinical care can be
Am J Prev Med 2002;22(4S)
17
Table 1. Outcomes reviewed for disease and case management interventions in diabetes
Patient
Patient knowledge
Intermediate (process) outcomes
Provider
Provider participation
Health insurance
Coverage, adequacy
Patient skills
Provider satisfaction
Problem-solving skills
Self-monitoring blood glucose
Provider productivity
Medication administration (including insulin)
Number of patients seen
Psychosocial outcomes
Self-efficacy
Health beliefs
Mood
Attitude
Coping skills
Self-assessed health status
Locus of control
Perceived barriers to adherence
Patient satisfaction with care
Screening and monitoring
Blood pressure
Glycemic control
Lipid levels
Retinopathy
Peripheral neuropathy
Microalbuminuria
Weight
Physiologic outcomes
Weight
Lipid levels
Foot lesions
Blood pressure
Microalbuminuria
Retinopathy
Provision of services
Regular source of care
Regular visits
Availability of patient education
Health care utilization
Number of admissions
Number of out-patient visits
Length of stay
Public health services
Availability
Quality
Provider treatment
Glycemic control
Cardiovascular disease
Hypertension
Nephropathy
Neuropathy
Retinopathy
Vaccination: pneumococcal, influenza
Use of ACE inhibitors
Use of aspirin
Short-term outcomes
Patient
Glycemic control
Glycated hemoglobin
Fasting blood glucose
Healthcare system
Long-term outcomes
Patient
Healthcare system
Macrovascular complications
Peripheral vascular disease
Coronary heart disease
Cerebrovascular disease
Economic outcomes
Outpatient utilization
Hospitalization rates
Cost
Cost-effectiveness/benefit
Microvascular complications
Decreased vision
Peripheral neuropathy
Renal disease
Foot ulcers
Amputations
Periodontal disease
Lifestyle
Physical activity
Diet
Smoking
Substance abuse
Quality of life
Disability/function
Mental health
Depression
Anxiety
Pregnancy-related outcomes
Neonatal morbidity and mortality
Maternal morbidity
Mortality
Work-related
Work days lost
Restricted duty days
Outcomes in bold are those on which the Task Force based its recommendations.
ACE, angiotensin-converting enzyme; CVD, cardiovascular disease.
obtained from the ADA29 and the U.S. Preventive Services
Task Force provides screening recommendations.50
Data Sources
The scientific literature was searched through December
2000 by using the MEDLINE database of the National Library
18
of Medicine (started in 1966), the Educational Resources
Information Center database (ERIC, 1966), the Cumulative
Index to Nursing and Allied Health database (CINAHL,
1982), and Healthstar (1975). The medical subject headings
(MeSH) searched were diabetes, case management, and disease
management, including all subheadings. Text word searches
American Journal of Preventive Medicine, Volume 22, Number 4S
were performed on multiple additional terms, including care
model, shared care, primary health care, medical specialties,
primary, or specialist. Abstracts were not included because
they generally had insufficient information to assess the
validity of the study using Community Guide criteria.22 Dissertations were also excluded, because the available abstracts
contained insufficient information for evaluation and the full
text was frequently unavailable. Titles of articles and abstracts
extracted by the search were reviewed for relevance, and if
potentially relevant the full-text article was retrieved. We also
reviewed the reference lists of included articles, and our
consultants provided additional relevant citations.
Study Selection
To be included in the review, studies had to (1) be primary
investigations of interventions selected for evaluation; (2) be
conducted in Established Market Economiesc; (3) provide
information on one or more outcomes of interest preselected
by the team (Table 1); and (4) meet minimum quality
standards.22 All types of comparative study designs were
included, including studies with concurrent or before-andafter comparison groups.
Data Abstraction and Synthesis
Community Guide rules of evidence characterize effectiveness
as strong, sufficient, or insufficient on the basis of the number
of available studies, the suitability of study designs for evaluating effectiveness, the quality of execution, the consistency
of the results, and effect sizes.22 Each study that met the
inclusion criteria was evaluated by using a standardized
abstraction form51 and assessed for suitability of its study
design and threats to internal validity, as described previously.22 Studies were characterized as having good, fair, or
limited quality of execution on the basis of the number of
threats to validity;22 only those with good or fair execution
were included. A summary effect measure (i.e., the difference
between the intervention and comparison group) was calculated for outcomes of interest. Absolute differences were used
for outcomes with consistent measurement scales (e.g.,
HbA1c and blood pressure) and relative differences for
outcomes with variable scales or weights of measurement
(e.g., quality of life). Interquartile ranges are presented as an
index of variability when seven or more studies were available
in the body of evidence; otherwise ranges are shown.
Summarizing Other Effects and Barriers
The Community Guide systematic review of disease and case
management in diabetes routinely sought information on
other effects (i.e., positive and negative health or nonhealth
“side effects”) and barriers to implementation (if there was
evidence of effectiveness); these effects were evaluated by the
systematic review development team and mentioned if they
were considered important.
c
Established Market Economies as defined by the World Bank are
Andorra, Australia, Austria, Belgium, Bermuda, Canada, Channel
Islands, Denmark, Faeroe Islands, Finland, France, Germany,
Gibraltar, Greece, Greenland, Holy See, Iceland, Ireland, Isle of Man,
Italy, Japan, Liechtenstein, Luxembourg, Monaco, the Netherlands,
New Zealand, Norway, Portugal, San Marino, Spain, St. Pierre and
Miquelon, Sweden, Switzerland, the United Kingdom, and the
United States.
Economic Evaluations
Methods for the economic evaluations in the Community Guide
were published in 2000.23 Reviews of studies reporting economic evaluations were performed only if the intervention
was found to be effective.
Summarizing Applicability
The body of evidence used to assess effectiveness was also
used to assess applicability. The systematic review development team and the Task Force drew conclusions about the
applicability of the available literature to various populations
and settings after examining data on patient and intervention
characteristics, settings, follow-up periods, methods of participant recruitment, and participation rates.
Summarizing Research Gaps
Systematic reviews in the Community Guide identify existing
information on which to base public health decisions about
implementing interventions. An important additional benefit
of these reviews is the identification of areas in which information is lacking or of poor quality. Where evidence of the
effectiveness of an intervention was sufficient or strong,
remaining questions about effectiveness, applicability, other
effects, economic consequences, and barriers to implementation are presented. In contrast, where the evidence of effectiveness of an intervention was insufficient, only research
questions relating to effectiveness and other effects are presented. Applicability issues are also included if they affected
the assessment of effectiveness. The team decided it would be
premature to identify research gaps in economic evaluations
or barriers before effectiveness was demonstrated.
Reviews of Evidence
Disease Management
Disease management has played a prominent role in
innovative systems of clinical care over the past two
decades. The earliest application of a disease-focused
intervention involved prescription drugs,52 and the first
use of the term disease management appears to have been
in the late 1980s at the Mayo Clinic.53 In the mid-1990s
the term emerged in the general medical literature,
and by 1999 approximately 200 companies offered
disease management services.54 The initial focus of
disease management was cost control, but, more recently, quality as well as economic efficiency have
driven disease management interventions. These interventions are used in several clinical care areas, primarily for costly, chronic diseases or conditions such as
heart failure,55,56 arthritis,57 and depression.58,59
The development of disease management has
spawned a variety of definitions and related terms. We
define disease management as an organized, proactive,
multicomponent approach to healthcare delivery that
involves all members of a population with a specific
disease entity such as diabetes. Care is focused on and
integrated across (1) the entire spectrum of the disease
and its complications, (2) the prevention of comorbid
Am J Prev Med 2002;22(4S)
19
Figure 2. Systematic review flow diagram.
n, number of studies; CINAHL, Cumulative Index to Nursing Allied Health.
conditions, and (3) the relevant aspects of the delivery
system. The goal is to improve short- and long-term
health or economic outcomes or both in the entire
population with the disease. The essential components
of disease management are (1) the identification of the
population with diabetes or a subset with specific
characteristics (e.g., cardiovascular disease risk factors),
(2) guidelines or performance standards for care,
(3) management of identified people, and (4) information systems for tracking and monitoring. Additional
interventions can be incorporated that focus on the
patient or population (e.g., diabetes self-management
education [DSME]), the provider (e.g., reminders or
continuing education), or the healthcare system or
practice (e.g., practice redesign in which “planned
improvements” are made in “the organization of practice to better meet the needs of the chronically ill”60).
Effectiveness. Our search identified 35 studies (in 36
reports) examining interventions that met our definition of disease management (Figure 2).61–96 The most
common reasons that studies did not meet our definition were that they did not use some form of practice
guidelines or that the entire target population was not
identified, monitored, and managed.25,97–123 Of the 35
studies, eight were not included because of multiple
limitations in execution, usually inadequate descriptive
information of the study population or intervention
characteristics, or inadequate statistical analyses.88 –95
20
Among the 27 remaining studies, design suitability22
was greatest in nine, moderate in three, and least
suitable in 15. Details of the 27 qualifying studies are
provided on the Community Guide website (www.
thecommunityguide.org).
The 27 studies provide evidence of effectiveness for
several patient and provider outcomes (Table 2). Effectiveness of disease management interventions on GHb
levels is shown in Figure 3 and on rates of provider
monitoring in Figure 4. GHb improved in 18 of 19
studies, with a median net change of ⫺0.5% (interquartile range, ⫺1.35% to ⫺0.1%). Strong evidence existed
for improvement in the percentage of providers performing annual monitoring of GHb and for retinopathy screening. Sufficient evidence was present of improvement in screening by providers for foot lesions or
peripheral neuropathy, lipid concentrations, and proteinuria (Figure 4). Evidence was insufficient to determine the effectiveness of disease management on other
important patient outcomes, including weight and
body mass index, blood pressure, and lipid concentrations, as few studies examined these outcomes and the
reported results were inconsistent.
Economic. Two economic studies were included in this
review. The first study, conducted in Scotland, reported
the average cost for adult patients of an integrated care
disease management intervention versus traditional
hospital clinic care.65 Integrated care patients were
American Journal of Preventive Medicine, Volume 22, Number 4S
Table 2. Effects of disease and case management interventions in diabetes.
Intervention
Intervention description
Provider monitoring and screening
Patient outcomes
Disease management
(n⫽27)
Disease management in the
clinical setting is an
organized, proactive,
multicomponent approach to
healthcare delivery, that
involves populations with
diabetes. Care is focused on
and integrated across the
entire spectrum of the disease
and its complications, the
prevention of comorbid
conditions, and the relevant
aspects of the delivery system.
GHb (n⫽15)⫹15.6% (interquartile range,
⫹4% to ⫹39%)63,65–67,70,71,77,78,81–87
Lipid concentrations (n⫽9) ⫹24%
(interquartile range, ⫹21% to
⫹26%)67,70,75,77,81,82,85–87
Dilated eye exams (n⫽15) ⫹9%
(interquartile range, ⫹3% to
⫹20%)63,65,71,72,75–77,79–85,87
Foot exams (n⫽9) ⫹26.5% (interquartile
range, ⫹10.9% to
⫹54%)65,67,71,75,76,79,81,85,87
Proteinuria (n⫽7) ⫹9.7% (interquartile
range, 0 to ⫹44%)61,70,75,79,82,83,87
Intermediate outcomes
Knowledge (n⫽1) improved in type 2 diabetes, deteriorated
in type 1 (p⬎0.05)65
Self-monitoring of blood glucose (n⫽1) improved
(p⬍0.0001)68
Self-efficacy (n⫽1) improved (p⬎0.05)68
Patient satisfaction (n⫽2) improved68,71
Healthcare utilization
Inpatient utilization (n⫽5) ⫺31% (⫺82.3% to
⫹11.4%)68,70,71,85,87
Number of visits (n⫽4) ⫺5.6% (⫺12.9% to
⫹25.8%)66,71,78,96
% patients with annual exam (n⫽3) ⫹7.7% (⫹2.7% to
⫹45.0%)79,82,84
Median follow-up for studies
examining GHb: 18 months
Physiologic outcomes
GHb (%) (n⫽19) ⫺0.5% (interquartile range, ⫺1.35% to
⫺0.1%)62–69,71,73,74,78–81,83,85,86,96
Weight (kg) (n⫽3) ⫹0.2 (⫺2.0 to ⫹2.8)79,83,96
Body mass index (kg/m2) (n⫽4) ⫹0.45 (⫺0.9 to
⫹1.5)64,65,69,73
Blood pressure (mmHg) (n⫽6) SBP ⫹0.9 (⫺10.0 to ⫹3.1);
DBP ⫺1.6 (⫺4.0 to ⫹0.1)64,65,69,70,87,96
Lipid concentrations (mg/dL) (n⫽4)64,86,87,96
Total cholesterol (n⫽2) ⫺4.796 and ⫺12.064
LDL (n⫽2) ⫺4.386 and ⫹4.296
Quality of life (n⫽1) improved (p⫽0.025)67
(continued on next page)
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22
Table 2. Effects of disease and case management interventions in diabetes (continued)
American Journal of Preventive Medicine, Volume 22, Number 4S
Intervention
Intervention description
Provider monitoring and screening
Patient outcomes
Case management
(n⫽15)
Case management is “a set of
activities whereby the needs of
populations of patients at risk
for excessive resource
utilization, poor outcomes, or
poor coordination of services
are identified and addressed
through improved planning,
coordination, and provision of
care.”126
GHb improved where case management was
combined with disease management (n⫽5)
⫹33% (interquartile range, ⫹13% to
⫹42%)66,67,70,77,85
Proteinuria (n⫽3) ⫹44%,70 ⫹63%,79 and
odds ratio 1.6561
Dilated eye exams (n⫽4) ⫹35% (⫹4% to
⫹76%)67,77,79,85
Foot exams (n⫽2) ⫹54%79 and ⫹84%67
Lipid testing (n⫽4) ⫹30% (⫹24 to
⫹44%)67,70,77,85
Self-efficacy (n⫽2) improved (p⫽0.01)137 and (p⫽0.26)68
Patient satisfaction with diabetes care (n⫽1) improved
(p⫽0.003)68
Self-monitoring of blood glucose (n⫽1) improved
(p⬍0.0001)68
Healthcare utilization
Inpatient utilization (n⫽4) median relative change ⫺18%
(⫺82% to ⫺18%)68–70,85
Annual visits (n⫽2) increase in one study (p⬎0.05),96
decrease in another66 (no statistics)
Median follow-up for studies
examining GHb: 12.5 months
Physiologic outcomes
GHb improved where case management was combined with
disease management (n⫽11) ⫺0.5% (interquartile range,
⫺0.65% to ⫺0.46%)62,66–68,73,79,85,96,135–137 and improved
where case management was implemented without disease
management (n⫽3) ⫺0.4% (⫺0.6% to ⫺0.16%)135–137
Lipid concentrations (mg/dL) (n ⫽ 3)
Total cholesterol (n⫽2) ⫺4.796 and 067
LDL (n⫽1) ⫹4.296
Body mass index (kg/m2) (n⫽1) ⫹0.373
Weight (kg) (n⫽4) 0.0 (⫺4.5 to ⫹16.8)79,96,135,138
Blood pressure (mmHg) (n⫽2)
SBP ⫺20.5138 and ⫺4.296
DBP ⫺6.1138 and ⫺2.396
Quality of life (n⫽2) improved in both studies (p⫽0.07),137
(p⫽0.025)67
Results presented are median effect sizes (range) unless otherwise specified. The results presented for provider monitoring and screening are the annual rates of provider performance of the tests
indicated, expressed as a percentage.
DBP, diastolic blood pressure; GHb, glycated hemoglobin; n, number of studies in the evidence set; NS, not significant; SBP, systolic blood pressure; LDL, low-density lipoprotein.
Figure 3. Effect of disease management on glycated hemoglobin. The study’s first author and the follow-up interval from end
of the intervention are shown on the y-axis. The absolute difference between the intervention and comparison group (post minus
pre value) is shown on the x-axis. Median effect, ⫺0.50%; interquartile range, ⫺1.35% to ⫺0.10%.
GHb, glycated hemoglobin; m, months.
seen in a general practice every 3 or 4 months and in
the hospital clinic annually. General practitioners and
patients received consultation reminders, patient
records were consistently updated, and practices received care guidelines. Traditional care patients were
Figure 4. Effect of disease management on provider monitoring rates. The y-axis represents absolute change in provider monitoring rates (percentage of providers performing
the test or screening in the last year) for each of the
interventions on the x-axis. The box plot indicates the median, interquartile range, and range; the mean is denoted by
a filled square.
seen at the clinic every 4 months and received appointment reminders. Costs included those associated with
general practice and clinic visits (staff, administrative,
overhead, and supply costs). The annual average adjusted costs were $143 to $185 for integrated care and
$101 for traditional care, resulting in a higher annual
average cost for the intervention of $42 to $84, adjusted
to the Community Guide reference case.23 After 2 years
no significant difference was seen between the two
groups for GHb, body mass index, creatinine, or blood
pressure. The integrated care patients, however, had
higher annual rates compared with the traditional care
group for routine diabetes care visits (5.3 versus 4.8)
and screening and monitoring of GHb (4.5 versus 1.3),
blood pressure (4.2 versus 1.2), and visual acuity (2.6
versus 0.7). This study was classified as good, based on
the quality assessment criteria used in the Community
Guide.23
The second study was a cost– benefit analysis of
preconception plus prenatal care versus prenatal care
only for women with established diabetes.124 Preconception care involved close interaction between the
patient and an interdisciplinary healthcare team (primary care and specialist physicians, nurse educator,
dietitian, and social worker), intensive evaluation, follow-up, testing, and monitoring to optimize glycemic
control and reduce adverse maternal and infant outcomes. The analysis modeled the program’s costs and
benefits, or savings, from reduced adverse maternal
and neonatal outcomes. Program costs included perAm J Prev Med 2002;22(4S)
23
sonnel, laboratory and other tests, supplies, outreach,
delivery, and time of the patient and a significant other.
Costs for maternal and neonatal adverse outcomes were
for hospital, physician, and subsequent neonatal care.
Costs attributable to future lost productivity of mother
and child were not included. The preconception care
intervention’s adjusted cost saving (net benefit) of
$2702 per enrollee was the difference between estimated prenatal care only and the preconception and
prenatal care intervention costs (program costs plus
maternal and neonatal adverse outcome costs). The
savings resulted largely from preventing the most expensive adverse events— congenital anomalies. The incremental benefit– cost ratio of 1.86 was the adverse
outcome cost savings of the preconception plus prenatal care intervention versus the prenatal-only program
divided by the difference in program costs. This ratio
represents the savings for each additional dollar invested in the preconception and prenatal care program
versus the prenatal care-only program. No effect size
was determined, as this was a modeling study relying on
secondary data. This study was classified as good, based
on the quality assessment criteria used in the Community
Guide.23
Applicability. These interventions were examined predominantly in two settings, community clinics62–
64,67,78,79,82,83,87
and managed care organizations, and
thus conclusions about their effectiveness apply specifically to these settings. The managed care organizations
included network or primary care-based models61,77,86,96
and
staff
or
group
model
HMOs.66,68,70,72,74,80,81,84,85 Other settings (academic
centers,73,76 a hospital clinic,65 and the Indian Health
Service69,75) were examined but did not provide sufficient data to determine the effectiveness of disease
management in those settings. The organizational components of community clinics and managed care delivery systems can differ from those in other delivery
systems, limiting how applicable the interventions are
in other types of delivery systems. However, findings in
HMOs may be applicable to other organized, inclusive
systems, such as the Indian Health Service.
Studies generally involved the entire population of
providers in a facility, although in some studies the
researchers selected specific providers to participate,72,78,84 or the providers volunteered.64,81,87 Researcher- or self-selected providers may have more of a
commitment to change or have greater skills in systems
change, the use of practice guidelines, or team approaches to care. Studies were conducted predominantly in urban centers in the United States62,66 –70,72–
78,80,84 – 86,96,125
and Europe.63– 65,79,81– 83,87
The body of evidence on disease management examined either adults with type 2 diabetes or populations
with mixed type 1 and 2 (predominantly type 2).
Although type 1 patients were not examined exclusively
24
in any study, these results likely apply to adults with type
1 disease. Despite important differences in characteristics between people with type 1 and type 2 diabetes,
including age of onset, incidence of ketoacidosis, exogenous insulin dependence, and use of oral hypoglycemic drugs, the goals of treatment and general management guidelines are identical. Thus, effective methods
of population management are likely to be similar for
adults with type 1 and type 2 diabetes. Effectiveness can
differ between children or adolescents and adults,
however, as parents likely serve as intermediaries between the healthcare system and the child. No studies
examined children with diabetes. No data were available on gestational diabetes (gestational diabetes develops in 2% to 3% of all pregnant women and disappears
with delivery1), but disease management interventions
likely apply to that population. Disease management
has been studied in minority and racially mixed populations,61,62,67,68,73,75,96 but it remains unclear how cultural characteristics can affect outcomes: access to these
interventions might also differ between minority and
Caucasian populations.
In summary, evidence for the effectiveness of disease
management is applicable to adults with diabetes in
managed care organizations and community clinics in
the United States and Europe.
Case Management
Case management is an important intervention for
people at high risk for adverse outcomes and excessive
healthcare utilization.126 It usually involves the assignment of authority to a professional (the case manager)
who is not the provider of direct health care but who
oversees and is responsible for coordinating and implementing care. In interventions involving diabetes, the
case manager is generally a nonphysician, most commonly a nurse.
Case management was first used in nursing and social
work as early as the 1850s,127 and the terminology has
evolved. The term care management is often used instead,
and the American Geriatrics Society prefers this term to
others.128 The effectiveness of case management has
been examined in a number of diseases, conditions,
and situations other than diabetes: psychiatric disorders,129 chronic congestive heart failure,130 geriatric
care,131 and care initiated at the time of hospital
discharge.132,133
Case management has five essential features:
(1) identification of eligible patients, (2) assessment,
(3) development of an individual care plan, (4) implementation of the care plan, and (5) monitoring of
outcomes. Patients are generally identified because of
high risk for excessive resource utilization, poor outcomes, or poor coordination of services. All people with
diabetes might be targeted, but more commonly a
subset with specific disease risk factors (e.g., coexisting
American Journal of Preventive Medicine, Volume 22, Number 4S
Figure 5. Effect of case management on glycated hemoglobin. The study’s first author and the follow-up interval from end of
the intervention are shown on the y-axis. An asterisk (*) indicates a study in which the intervention included disease management
in addition to case management. The absolute difference between the intervention and comparison group (post value minus pre
value) is shown on the x-axis. Median effect, ⫺0.53%; interquartile range, ⫺0.65% to ⫺0.46%.
GHb, glycated hemoglobin; m, months.
cardiovascular disease or poor glycemic control) or
high utilization (e.g., as determined by visits or costs) is
targeted. After the population for case management
has been identified, each individual patient’s needs are
comprehensively assessed, and an individual care plan
is developed and implemented. Monitoring of the
individual patient or population can involve process
(e.g., patient satisfaction, service utilization), health,
quality of life, or economic outcomes (e.g., cost, hospital admissions).
Case management interventions are often incorporated into multicomponent interventions, making it
difficult to assess the effectiveness of case management
itself. As Wagner134 pointed out, these interventions
can be “more than a case manager” and can be
implemented in healthcare systems that encompass a
more responsive system of care for the chronically ill
along with other population-based interventions. Interventions that can be combined with case management
include self-management education, home visits, telephone call outreach, telemedicine, and patient
reminders.
Effectiveness. We identified 24 studies (in 27 reports)
that examined the effectiveness of diabetes case management.61,62,66 – 68,70,73,77,79,85,89,93,96,101,135–147 Seven
studies were excluded because of multiple limitations
in quality, usually inadequate descriptive information
of the study population and intervention characteristics, or inadequate statistical analyses,93,101,139 –143 and
two146,147 were excluded for lack of relevant outcomes.
Among the 15 qualifying studies, design suitability was
greatest for 8, moderate for 1, and least suitable for 6.
Details of the studies are found in Appendix A and at
the website (www.thecommunityguide.org). The 15
studies provided data on numerous provider and patient outcomes (Table 2). Effectiveness of case management interventions on GHb is shown in Figure 5.
Improvement in GHb was similar when case management was delivered in addition to disease management
and when it was not. When case management was
delivered with disease management, evidence was sufficient of its effect on provider monitoring of GHb.
When examined without disease management, or in
combination with disease management, evidence was
insufficient of the effect of case management on lipid
concentrations, weight or body mass index, and blood
pressure, as studies were few, with inconsistent results.
Quality of life improved in two studies.67,137
Economic. No studies were found that met the requirements for inclusion in a Community Guide review.23
Applicability. Except for one study in the United Kingdom,79 all studies were performed in the United States.
Settings were primarily managed care organizaAm J Prev Med 2002;22(4S)
25
tions,61,66,68,70,77,85,96,137 although an academic center,73 community clinics,62,67,79,138,145 a U.S. military
clinic,135 and a U.S. veterans hospital69,136 were included as well. In most studies the entire eligible
population of providers at a clinic or in a healthcare
organization was recruited to participate, but in three
studies the researcher selected a subset of
providers.137,138,144
Study populations were predominantly mixed by
gender and race, and they were mainly adults with type
2 diabetes. One study137 was of children with type 1
diabetes (mean age, 9.8 years). In numerous studies
demographic information was missing, including age
and type of diabetes.
Case management was implemented along with disease management in many of the studies.61,62,66,68,73,77,79,85,89,96,145 In other studies additional
interventions were used, including DSME,136,137 telemedicine support,135 insulin-adjustment algorithms,137
group support,137 visit reminders,136 and hospital discharge assessment and follow-up.69 It was not possible
to determine the isolated effect of case management in
these studies.
In summary, the evidence for the effectiveness of
case management is applicable primarily in the U.S.
managed care setting for adults with type 2 diabetes.
The intervention is effective both when delivered in
conjunction with disease management and when delivered with one or more educational, reminder, or
support interventions.
Other Issues Related to Disease and Case
Management
Other positive or negative effects. In addition to the
positive effects of disease and case management discussed above, the Task Force identified an additional
potential benefit in that the organized and evidencebased approach to care in diabetes can be extended to
other diseases and healthcare needs in an organization.
The same kind of infrastructure that supports diabetes
disease and case management interventions, including
information systems, practice guidelines, and support
staff training and resources, could be used for the care
of people with cardiovascular disease, mental health
disorders, or chronic pain or for the delivery of preventive services (e.g., immunization of adults and children
by using registries and reminder/recall systems). To
our knowledge, however, this potential benefit has not
yet been evaluated in the literature.
Barriers to implementation. The systematic review development team identified potential barriers at the
level of the organization, the provider or support staff,
or the patient when implementing disease and case
management interventions, although these were not
evaluated in this body of literature. Barriers at the
organizational level include a deficiency of organiza26
tional leadership to support these interventions and the
unavailability of financial resources necessary for implementation and maintenance. Furthermore, the organization may not have practice guidelines or the necessary skills and resources to develop guidelines, which
can be perceived as a barrier. (Several practice guidelines are publicly available, such as the guidelines
published annually by the ADA.148)
For providers practicing in the traditional mode of
reactive care, the switch to proactive, organized management requires the redesign of much of their practice and approach to patient care: appointment and
follow-up scheduling; allocation of clinic time to review
registries and practice guidelines; delineation of the
roles of support staff and providers; the delegation of
care traditionally performed by physicians to other
professionals, such as nurses; team organization; and
the use of planned visits and patient reminders.60,149,150
Providers can find disease management time-consuming, particularly initially, and they can be inexperienced or uncomfortable with information systems. Barriers for using practice guidelines, described
elsewhere,151 include lack of awareness of or familiarity
with them, disagreement with the guidelines, lack of
confidence that patient outcomes can be improved,
inability to overcome the inertia of previous practice,
and external barriers such as inconvenience and insufficient time. In addition, little or no reimbursement
may be available for delivering patient reminders and
other proactive care strategies. Identifying patients to
participate in these interventions may also be difficult.
Patients can be identified, however, from provider and
staff memory, hospital discharge summaries, claims
data,152,153 visit encounter forms, laboratory test results,
patient-initiated visits, or pharmacy activity. Patient
barriers include difficulties in maintaining healthy lifestyles and the complexity of self-management required
for diabetes management.154
Research Issues for Disease and Case Management
Interventions in Diabetes
Even though disease and case management were found
effective in the managed care setting for improving
glycemic control and provider monitoring of certain
important outcomes, several important research gaps
were identified in this review. One of the most pressing
needs is to better define effective interventions. Disease
management has multiple component interventions.
To make optimal use of resources, however, only the
interventions that contribute most to positive outcomes
should be implemented, and these interventions need
to be defined. Case management interventions are
usually delivered with other interventions, and the
effectiveness of these other interventions also needs to
be defined. Are case management interventions delivered with disease management more effective than case
American Journal of Preventive Medicine, Volume 22, Number 4S
management delivered as a single intervention? Are
there specific additional interventions that augment
the effectiveness of disease and case management, such
as DSME? Additional research questions relating to
case management include identifying the optimal intensity (frequency and duration) of patient contact and
determining whether professionals other than nurses
(e.g., social workers or pharmacists) could function as
case managers.
How best to integrate disease and case management
interventions into existing healthcare systems also
needs to be addressed. What are the strengths and
limitations of delivering these interventions as part of
primary care or specialty care, or might they best be
delivered by contracted organizations and provider
networks that are separate from the patient’s healthcare delivery system (i.e., the carve-out model)?155
Although the existing effectiveness literature examines many important outcomes, research is needed to
determine the effect of disease and case management
on long-term health and quality of life outcomes,
including cardiovascular disease events, renal failure,
visual impairment, amputations, and mortality. Further
work is also needed to determine the effect of case
management on blood pressure, weight, lipid concentrations, and provider screening rates for retinopathy,
peripheral neuropathy, and microalbuminuria. In addition, provider and patient satisfaction with these interventions needs much more attention from researchers.
As discussed earlier, the applicability of these data is
somewhat limited, leaving numerous important questions unanswered. For example, are disease and case
management effective in settings other than HMOs and
community clinics, such as academic clinics and independent private practices? Do these interventions work
better in some types of delivery systems than others?
Are they effective for adolescents with diabetes? How
do the cultural, educational, and socioeconomic characteristics of a population affect outcomes? What are
the key barriers that providers perceive for disease and
case management? How would it be best to obviate
them? Do patients perceive any barriers to these
interventions?
Numerous deficiencies in the methodologies of these
studies were identified. Often there was inadequate
descriptive information; studies need to include adequate demographic information (at a minimum, age,
gender, race or ethnicity, and type of diabetes), a
description of the delivery system infrastructure (automated information systems, prior use of guidelines,
resource support, management [medical and nonmedical] commitment and support), and details of the
intervention (components, frequency and duration of
patient contact, who delivered the intervention,
whether and which clinical practice guidelines were
used, and degree and type of interface with primary
care). In addition, more studies are needed with a
concurrent comparison group to control for secular
trends in healthcare delivery and patient practices.
Finally, studies are needed in which a broad range of
providers is recruited.
Conclusions
According to Community Guide rules of evidence,22
strong evidence exists that disease management interventions are effective in improving glycemic control in
people with diabetes and in improving provider monitoring of GHb and screening for diabetic retinopathy.
There is sufficient evidence that disease management is
effective in improving provider screening for foot lesions and peripheral neuropathy, screening of urine for
protein, and monitoring of lipid concentrations. For
case management, evidence is strong of its effectiveness
in improving glycemic control. When case management is delivered along with disease management,
evidence is sufficient that it is effective in improving
provider monitoring of GHb. Deficiencies in methodology of the existing literature were identified, and
research gaps noted, particularly in the areas of effectiveness of specific components of these interventions,
effects on long-term health and quality of life outcomes, and application to diverse populations and
settings.
The authors thank Stephanie Zaza, MD, MPH, for support,
technical assistance, and editorial review; Kristi Riccio, BSc,
for technical assistance; and Kate W. Harris, BA, for editorial
and technical assistance. The authors acknowledge the following consultants for their contribution to this manuscript:
Tanya Agurs-Collins, PhD, Howard University Cancer Center,
Washington, DC; Ann Albright, PhD, RD, California Department of Health Services, Sacramento; Pam Allweiss, MD,
Lexington, KY; Elizabeth Barrett-Connor, MD, University of
California, San Diego; Richard Eastman, MD, Cygnus, San
Francisco, CA; Luis Escobedo, MD, New Mexico Department
of Health, Las Cruces; Wilfred Fujimoto, MD, University of
Washington, Seattle; Richard Kahn, PhD, American Diabetes
Association, Alexandria VA; Robert Kaplan, PhD, University
of California, San Diego; Shiriki Kumanyika, PhD, University
of Pennsylvania, Philadelphia; David Marrerro, PhD, Indiana
University, Indianapolis; Marjorie Mau, MD, Honolulu, HI;
Nicolaas Pronk, PhD, HealthPartners, Minneapolis, MN; Laverne Reid, PhD, MPH, North Carolina Central University,
Durham; Yvette Roubideaux, MD, MPH, University of Arizona, Tucson.
The authors also thank Semra Aytur, MPH, Inkyung Baik,
PhD, Holly Murphy MD, MPH, Cora Roelofs, ScD, and Kelly
Welch, BSc, for assisting us in abstracting data from the
studies included in this review.
References
1. U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention. National diabetes fact sheet. 1998. Available at:
www.cdc.gov/diabetes/pubs/facts98.htm.
Am J Prev Med 2002;22(4S)
27
2. American Diabetes Association. Economic consequences of diabetes mellitus in the U.S. in 1997. Diabetes Care 1998;21:296 –309.
3. Selby JV, Ray GT, Zhang D, Colby CJ. Excess costs of medical care for
patients with diabetes in a managed care population. Diabetes Care
1997;20:1396 – 402.
4. Glasgow RE, Hiss RG, Anderson RM, et al. Report of the Health Care
Delivery Work Group: behavioral research related to the establishment of
a chronic disease model for diabetes care. Diabetes Care 2001;24:124 –30.
5. Glasgow RE, Strycker LA. Preventive care practices for diabetes management in two primary care samples. Am J Prev Med 2000;19:9 –14.
6. Peters AL, Legorreta AP, Ossorio RC, Davidson MB. Quality of outpatient
care provided to diabetic patients. A health maintenance organization
experience. Diabetes Care 1996;19:601– 6.
7. Klonoff DC, Schwartz DM. An economic analysis of interventions for
diabetes. Diabetes Care 2000;23:390 – 404.
8. Gilmer TP, O’Connor PJ, Manning WG, Rush WA. The cost to health
plans of poor glycemic control. Diabetes Care 1997;20:1847–53.
9. Testa MA, Simonson DC. Health economic benefits and quality of life
during improved glycemic control in patients with type 2 diabetes
mellitus. JAMA 1998;280:1490 – 6.
10. Wagner EH, Sandhu N, Newton KM, McCulloch DK, Ramsey SD, Grothaus LC. Effect of improved glycemic control on health care costs and
utilization. JAMA 2001;285:182–9.
11. Task Force on Community Preventive Services. Introducing the Guide to
Community Preventive Services: methods, first recommendations and
expert commentary. Am J Prev Med 2000;18(suppl 1):1–142.
12. Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18(suppl 1):92– 6.
13. Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding
interventions to improve vaccination coverage in children, adolescents,
and adults. The Task Force on Community Preventive Services. Am J Prev
Med 2000;18(suppl 1):97–140.
14. Centers for Disease Control and Prevention. Vaccine-preventable diseases:
improving vaccination coverage in children, adolescents, and adults. A
report on recommendations of the Task Force on Community Preventive
Services. MMWR Morb Mortal Wkly Rep 1999;48(RR-8):1–15.
15. Centers for Disease Control and Prevention. Strategies for reducing
exposure to environmental tobacco smoke, increasing tobacco-use cessation, and reducing initiation in communities and health-care systems. A
report on recommendations of the Task Force on Community Preventive
Services. MMWR Morb Mortal Wkly Rep 2000;49(RR-12):1–11.
16. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental
tobacco smoke. Am J Prev Med 2001;20(suppl 2):10 –5.
17. Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding
interventions to reduce tobacco use and exposure to environmental
tobacco smoke. Am J Prev Med 2001;20(suppl 2):16 – 66.
18. Centers for Disease Control and Prevention. Motor vehicle occupant
injury: strategies for increasing use of child safety seats, increasing use of
safety belts, and reducing alcohol-impaired driving. MMWR Morb Mortal
Wkly Rep 2001;50(RR-7):1–16.
19. Zaza S, Sleet DA, Thompson RS, Sosin DM, Bolen JC, Task Force on
Community Preventive Services. Reviews of evidence regarding interventions to increase use of child safety seats. Am J Prev Med 2001;21(suppl
4):31– 47.
20. U.S. Department of Health and Human Services. Healthy people 2010,
2nd ed. Washington, DC: U.S. Government Printing Office; 2000.
21. Task Force on Community Preventive Services. Recommendations for
healthcare system and self-management education interventions to reduce morbidity and mortality from diabetes. Am J Prev Med 2002;
22(suppl 4):10 –14.
22. Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based
Guide to Community Preventive Services—methods. The Task Force on
Community Preventive Services. Am J Prev Med 2000;18(suppl 1):35– 43.
23. Carande-Kulis VG, Maciosek MV, Briss PA, et al. Methods for systematic
review of economic evaluations for the Guide to Community Preventive
Services. The Task Force on Community Preventive Services. Am J Prev
Med 2000;18(suppl 1):75–91.
24. Norris SL, Nichols PJ, Caspersen CJ, et al., and the Task Force on
Community Preventive Services. Increasing diabetes self-management
education in community settings: a systematic review. Am J Prev Med
2002;22(suppl 4):39 – 66.
25. The Diabetes Control and Complications Trial Research Group. The
effect of intensive treatment of diabetes on the development and progres-
28
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
sion of long-term complications in insulin-dependent diabetes mellitus.
N Engl J Med 1993;329:977– 86.
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose
control with sulphonylureas or insulin compared with conventional
treatment and risk of complications in patients with type 2 diabetes
(UKPDS 33). Lancet 1998;352:837–53.
UK Prospective Diabetes Study Group. Tight blood pressure control and
risk of macrovascular and microvascular complications in type 2 diabetes
(UKPDS 38). Br Med J 1998;317:703–13.
Fontbonne A, Eschwege E, Cambien F, et al. Hypertriglyceridaemia as a
risk factor of coronary heart disease mortality in subjects with impaired
glucose tolerance or diabetes. Results from the 11-year follow-up of the
Paris Prospective Study. Diabetologia 1989;32:300 – 4.
American Diabetes Association. Standards of medical care for patients
with diabetes mellitus. Diabetes Care 2001;24(suppl 1):S33–S55.
American Diabetes Association. Preventive foot care in people with
diabetes. Diabetes Care 2001;24(suppl 1):S56 –S57.
American Diabetes Association. Management of dyslipidemia in adults
with diabetes. Diabetes Care 2001;24(suppl 1):S58 –S61.
American Diabetes Association. Tests of glycemia in diabetes. Diabetes
Care 2001;24(suppl 1):S80 –S82.
Ravid M, Lang R, Rachmani R, Lishner M. Long-term renoprotective
effect of angiotensin-converting enzyme inhibition in non-insulin-dependent diabetes mellitus. A 7-year follow-up study. Arch Intern Med 1996;
156:286 –9.
American Diabetes Association. Diabetic retinopathy. Diabetes Care 2001;
24(suppl 1):S73–S76.
Bild DE, Selby JV, Sinnock P, Browder WS, Braveman P, Showstack JA.
Lower extremity amputation in people with diabetes. Epidemiology and
prevention. Diabetes Care 1989;12:24 –31.
Rith-Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at
high risk for lower-extremity amputation in a primary health care setting.
A prospective evaluation of simple screening criteria. Diabetes Care
1992;15:1386 –9.
Early Treatment Diabetic Retinopathy Study Research Group. Early
photocoagulation for diabetic retinopathy. ETDRS Report Number 9.
Ophthalmology 1991;98:766 – 85.
Lockington TJ, Farrant S, Meadown KA, Dowlatshahi D, Wise PH.
Knowledge profile and control in diabetic patients. Diabet Med 1988;5:
381– 6.
Grembowski D, Patrick D, Diehr P, et al. Self-efficacy and health behavior
among older adults. J Health Soc Behav 1993;34:89 –104.
Wilson W, Ary DV, Biglan A, Glasgow RE, Toobert DJ, Campbell DR.
Psychosocial predictors of self-care behaviors (compliance) and glycemic
control in non-insulin-dependent diabetes mellitus. Diabetes Care 1986;
9:614 –22.
Peyrot M. Behavior change in diabetes education. Diabetes Educ 1999;25
(suppl 6):62–73.
Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents
the progression of diabetic microvascular complications in Japanese
patients with non-insulin-dependent diabetes mellitus: a randomized
prospective 6-year study. Diabetes Res Clin Pract 1995;28:103–17.
Wake N, Hisashige A, Katayama T, et al. Cost-effectiveness of intensive
insulin therapy for type 2 diabetes: a 10-year follow-up of the Kumamoto
study. Diabetes Res Clin Pract 2000;48:201–10.
Reaven GM. Beneficial effect of moderate weight loss in older patients
with non-insulin-dependent diabetes mellitus poorly controlled with insulin. J Am Geriatr Soc 1985;33:93–5.
Wing RR, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker D.
Long-term effects of modest weight loss in type II diabetic patients. Arch
Intern Med 1987;147:1749 –53.
Watts NB, Spanheimer RG, DiGirolamo M, et al. Prediction of glucose
response to weight loss in patients with non-insulin-dependent diabetes
mellitus. Arch Intern Med 1990;150:803– 6.
American Diabetes Association. Nutrition recommendations and principles for people with diabetes mellitus. Diabetes Care 2001;24(suppl
1):S44 –S47.
American Diabetes Association. Diabetes mellitus and exercise. Diabetes
Care 2001;24(suppl 1):S51–S55.
Bakris GL, Williams M, Dworkin L, et al. Preserving renal function in
adults with hypertension and diabetes: a consensus approach. National
Kidney Foundation Hypertension and Diabetes Executive Committees
Working Group. Am J Kidney Dis 2000;36:646 – 61.
U.S. Preventive Services Task Force. Screening for diabetes mellitus.
American Journal of Preventive Medicine, Volume 22, Number 4S
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
Guide to clinical preventive services. Alexandria, VA: International Medical Publishing, 1996:193–208.
Zaza S, Wright-De Aguero LK, Briss P, et al. Data collection instrument
and procedure for systematic reviews in the Guide to Community Preventive Services. Am J Prev Med 2000;18(suppl 1):44 –74.
Kesteloot K. Disease management. A new technology in need of critical
assessment. Int J Technol Assess Health Care 1999;15:506 –19.
Zitter M. A new paradigm in health care delivery: disease management. In:
Todd WE, Nash E, eds. Disease management: a systems approach to
improving patient outcomes. Chicago, IL: American Hospital Publishing,
Inc., 1997:1–26.
Bodenheimer T. Disease management in the American market. Br Med J
2000;320:563– 6.
Roglieri JL, Futterman R, McDonough KL, et al. Disease management
interventions to improve outcomes in congestive heart failure. Am J
Manag Care 1997;3:1831–9.
Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney
RM. A multidisciplinary intervention to prevent the readmission of elderly
patients with congestive heart failure. N Engl J Med 1995;333:1190 –5.
Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic
disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care 1999;37:5–14.
Lin EH, VonKorff M, Russo J, et al. Can depression treatment in primary
care reduce disability? A stepped care approach. Arch Fam Med 2000;9:
1052– 8.
Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating
quality improvement programs for depression in managed primary care:
a randomized controlled trial. JAMA 2000;283:212–20.
Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic
illness. Manag Care Q 1996;4:12–25.
Sikka R, Waters J, Moore W, Sutton DR, Herman WH, Aubert RE. Renal
assessment practices and the effect of nurse case management of health
maintenance organization patients with diabetes. Diabetes Care 1999;22:
1– 6.
Legorreta A, Peters A, Ossorio RC, Lopez R, Jatulis D, Davidson M. Effect
of a comprehensive nurse-managed diabetes program: an HMO prospective study. Am J Manag Care 1996;2:1024 –30.
Carlson A, Rosenqvist U. Diabetes care organization, process, and patient
outcomes: effects of a diabetes control program. Diabetes Educ 1991;17:
42– 8.
de Sonnaville JJ, Bouma M, Colly LP, Deville W, Wijkel D, Heine RJ.
Sustained good glycaemic control in NIDDM patients by implementation
of structured care in general practice: 2-year follow-up study. Diabetologia
1997;40:1334 – 40.
Diabetes Integrated Care Evaluation Team. Integrated care for diabetes:
clinical, psychosocial, and economic evaluation. Br Med J 1994;308:1208 –
12.
O’Connor PJ, Rush WA, Peterson J, et al. Continuous quality improvement can improve glycemic control for HMO patients with diabetes. Arch
Fam Med 1996;5:502– 6.
Peters AL, Davidson MB. Application of a diabetes managed care program. The feasibility of using nurses and a computer system to provide
effective care. Diabetes Care 1998;21:1037– 43.
Sadur CN, Moline N, Costa M, et al. Diabetes management in a health
maintenance organization. Efficacy of care management using cluster
visits. Diabetes Care 1999;22:2011–7.
Tom-Orme L. Chronic disease and the social matrix: a Native American
diabetes intervention. Recent Adv Nurs 1988;22:89 –109.
Domurat ES. Diabetes managed care and clinical outcomes: the Harbor
City, California Kaiser Permanente diabetes care system. Am J Manag Care
1999;5:1299 –307.
McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. A population-based
approach to diabetes management in a primary care setting: early results
and lessons learned. Eff Clin Pract 1998;1:12–22.
Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting populationbased care into practice: real option or rhetoric? J Am Board Fam Pract
1998;11:116 –26.
Cook CB, Ziemer DC, El-Kebbi IM, et al. Diabetes in urban AfricanAmericans. XVI. Overcoming clinical inertia improves glycemic control in
patients with type 2 diabetes. Diabetes Care 1999;22:1494 –500.
Sidorov J, Gabbay R, Harris R, et al. Disease management for diabetes
mellitus: impact on hemoglobin A1c. Am J Manag Care 2000;6:1217–26.
Acton K, Valway S, Helgerson S, et al. Improving diabetes care for
American Indians. Diabetes Care 1993;16:372–5.
Casey DE Jr, Egede LE. Effect of a disease management tool on residents’
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
compliance with American Diabetes Association standard of care for type
2 diabetes mellitus. American Diabetes Association. Md Med J 1999;48:
119 –21.
Chicoye L, Roethel CR, Hatch MH, Wesolowski W. Diabetes care management: a managed care approach. WMJ 1998;97:32– 4.
Deichmann R, Castello E, Horswell R, Friday KE. Improvements in
diabetic care as measured by HbA1c after a physician education project.
Diabetes Care 1999;22:1612– 6.
Foulkes A, Kinmonth AL, Frost S, MacDonald D. Organized personal
care—an effective choice for managing diabetes in general practice. J R
Coll Gen Pract 1989;39:444 –7.
Friedman NM, Gleeson JM, Kent MJ, Foris M, Rodriguez DJ, Cypress M.
Management of diabetes mellitus in the Lovelace Health Systems’ EPISODES OF CARE program. Eff Clin Pract 1998;1:5–11.
Goldfracht M, Porath A. Nationwide program for improving the care of
diabetic patients in Israeli primary care centers. Diabetes Care 2000;23:
495–9.
Johnston C, Ponsonby E. Northwest Herts diabetic management system.
Comput Methods Programs Biomed 2000;62:177– 89.
North Tyneside Diabetes Team. The diabetes annual review as an educational tool: assessment and learning integrated with care, screening, and
audit. Diabet Med 1992;9:389 –94.
Payne TH, Galvin M, Taplin SH, Austin B, Savarino J, Wagner EH.
Practicing population-based care in an HMO: evaluation after 18 months.
HMO Pract 1995;9:101– 6.
Rubin RJ, Dietrich KA, Hawk AD. Clinical and economic impact of
implementing a comprehensive diabetes management program in managed care. J Clin Endocrinol Metab 1998;83:2635– 42.
Sperl-Hillen J, O’Connor PJ, Carlson RR, et al. Improving diabetes care in
a large health care system: an enhanced primary care approach. Jt Comm
J Qual Improv 2000;26:615–22.
Varroud-Vial M, Mechaly P, Joannidis S, et al. Cooperation between
general practitioners and diabetologists and clinical audit improve the
management of type 2 diabetic patients. Diabetes Metab 1999;25:55– 63.
Anonymous. Disease management program improves diabetes outcomes,
curbs hospital costs, utilization. Health Care Cost Reengineering Rep
1998;3:42–5.
Davidson MB. Incorporating diabetes care into a health maintenance
organization setting: a practical guide. Disease Manage Health Outcomes
1998;3:71– 80.
Wells S, Benett I, Holloway G, Harlow V. Area-wide diabetes care: the
Manchester experience with primary health care teams 1991–1997. Diabet
Med 1998;15(suppl 3):S49 –S53.
Williams DR, Munroe C, Hospedales CJ, Greenwood RH. A three-year
evaluation of the quality of diabetes care in the Norwich community care
scheme. Diabet Med 1990;7:74 –9.
Day JL, Humphreys H, Alban-Davies H. Problems of comprehensive
shared diabetes care. Br Med J 1987;294:1590 –2.
Joshi MS, Bernard DB. Clinical performance improvement series. Classic
CQI integrated with comprehensive disease management as a model for
performance improvement. Jt Comm J Qual Improv 1999;25:383–95.
Kelling DG, Wentworth JA, Wright JB. Diabetes mellitus. Using a database
to implement a systematic management program. N C Med J 1997;58:
368 –71.
Rosenthal MM, Carlson A, Rosenqvist U. Beyond CME: diabetes education
field-interactive strategies from Sweden. Diabetes Educ 1988;14:212–7.
Aubert RE, Herman WH, Waters J, et al. Nurse case management to
improve glycemic control in diabetic patients in a health maintenance
organization. A randomized, controlled trial. Ann Intern Med 1998;129:
605–12.
Adams CE, Wilson M. Enhanced quality through outcome-focused standardized care plans. J Nurs Adm 1995;25:27–34.
Bowyer NK. A primary care team approach to the prevention of ocular
complications of diabetes: a program review. J Am Optom Assoc 1997;68:
233– 42.
Branger PJ, van’t Hooft A, van der Wouden JC, Moorman PW, van
Bemmel JH. Shared care for diabetes: supporting communication between primary and secondary care. Int J Med Inf 1999;53:133– 42.
Dargis V, Pantelejeva O, Jonushaite A, Vileikyte L, Boulton AJ. Benefits of
a multidisciplinary approach in the management of recurrent diabetic
foot ulceration in Lithuania: a prospective study. Diabetes Care 1999;22:
1428 –31.
Day JL, Johnson P, Rayman G, Walker R. The feasibility of a potentially
‘ideal’ system of integrated diabetes care and education based on a day
centre. Diabet Med 1988;5:70 –5.
Am J Prev Med 2002;22(4S)
29
102. Deeb LC, Pettijohn FP, Shirah JK, Freeman G. Interventions among
primary-care practitioners to improve care for preventable complications
of diabetes. Diabetes Care 1988;11:275– 80.
103. Drozda DJ, Dawson VA, Long DJ, Freson LS, Sperling MA. Assessment of
the effect of a comprehensive diabetes management program on hospital
admission rates of children with diabetes mellitus. Diabetes Educ 1990;
16:389 –93.
104. Falkenberg M. Metabolic control and amputations among diabetics in
primary health care—a population-based intensified programme governed by patient education. Scand J Prim Health Care 1990;8:25–9.
105. Fischer U, Salzsieder E, Menzel R, et al. Primary health care of diabetic
patients in a specialized outpatient setting: a DIABCARE-based analysis.
Diabete Metab 1993;19:188 –94.
106. Fox A. Defining and implementing intensive diabetes management: a
pilot study. Can J Diabetes Care 1995;19:14 –20.
107. Halbert RJ, Leung KM, Nichol JM, Legorreta AP. Effect of multiple
patient reminders in improving diabetic retinopathy screening. A randomized trial. Diabetes Care 1999;22:752–5.
108. Hellman R, Regan J, Rosen H. Effect of intensive treatment of diabetes on
the risk of death or renal failure in NIDDM and IDDM. Diabetes Care
1997;20:258 – 64.
109. Hoskins P, Alford J, Fowler P, et al. Outpatient stabilization programme—an innovative approach in the management of diabetes. Diabetes Res 1985;2:85– 8.
110. Lorenz RA, Pichert JW, Enns SJ, Hanson SL. Impact of organizational
interventions on the delivery of patient education in a diabetes clinic.
Patient Educ Couns 1986;8:115–23.
111. Miller L, Goldstein J. More efficient care of diabetic patients in a county
hospital setting. N Engl J Med 1972;286:1388 –91.
112. Nordfeldt S, Jonsson D, Ludvigsson J. Increasing response rate in data
registration and follow-up of children and adolescents with type 1
diabetes: a prospective population study 1992–97. Practical Diabetes Int
1999;16:101– 6.
113. Ollendorf DA, Kotsanos JG, Wishner WJ, et al. Potential economic
benefits of lower-extremity amputation prevention strategies in diabetes.
Diabetes Care 1998;21:1240 –5.
114. Overland J, Mira M, Yue DK. Diabetes management: shared care or shared
neglect. Diabetes Res Clin Pract 1999;44:123– 8.
115. Porter AM. Organisation of diabetic care. Br Med J 1982;285:1121.
116. Scheffler RM, Feuchtbaum LB, Phibbs CS. Prevention: the cost-effectiveness of the California Diabetes and Pregnancy Program. Am J Public
Health 1992;82:168 –75.
117. Smith SA, Murphy ME, Huschka T, et al. Impact of a diabetes electronic
management system on the care of patients seen in a subspecialty diabetes
clinic. Diabetes Care 1998;21:972– 6.
118. Solberg LI, Reger LA, Pearson TL, et al. Using continuous quality
improvement to improve diabetes care in populations: the IDEAL model.
Improving care for diabetics through Empowerment Active Collaboration
and Leadership. Jt Comm J Qual Improv 1997;23:581–92.
119. Stuart ME. Redefining boundaries in the financing and care of diabetes:
the Maryland experience. Milbank Q 1994;72:679 –94.
120. Visser AP, Schouten JA, van der Veen EA, van den Boogaard PR. Benefits
of intensive treatment of insulin-dependent diabetes patients: the importance of patient education. Patient Educ Couns 1989;14:21–9.
121. Weinberger M, Smith DM, Katz BP, Moore PS. The cost-effectiveness of
intensive postdischarge care: a randomized trial. Med Care 1988;26:1092–
102.
122. Wilczynski J, Cypryk K, Zawodniak-Szalapska M, et al. The role of staged
diabetes management in improving diabetes care in Poland. Practical
Diabetes Int 1999;16:137– 41.
123. York R, Brown LP, Samuels P, et al. A randomised trial of early discharge
and nurse specialist transitional follow-up care of high-risk childbearing
women. Nurs Res 1997;46:254 – 61.
124. Elixhauser A, Weschler JM, Kitzmiller JL, et al. Cost-benefit analysis of
preconception care for women with established diabetes mellitus. Diabetes Care 1993;16:1146 –57.
125. McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. Improvement in
diabetes care using an integrated population-based approach in a primary
care setting. Dis Manag 2000;3:75– 82.
126. Institute for Clinical Systems Integration. Technology assessment: care
management for chronic illness, the frail elderly, and acute myocardial
infarction. Bloomington, MN: Institute for Clinical Systems Integration
(ICSI), 1998:44.
127. Ward MD, Rieve JA. The role of case management in disease management. In: Todd WE, Nash E, eds. Disease management: a systems
30
128.
129.
130.
131.
132.
133.
134.
135.
136.
137.
138.
139.
140.
141.
142.
143.
144.
145.
146.
147.
148.
149.
150.
151.
152.
153.
154.
155.
approach to improving patient outcomes. Chicago, IL: American Hospital
Publishing, 1997:235–59.
American Geriatric Society Public Policy Committee. Care management.
J Am Geriatr Soc 1991;39:429 –30.
Holloway F, Oliver N, Collins E, Carson J. Case management: a critical
review of the outcome literature. Eur Psychiatry 1995;10:113–28.
Brass-Mynderse NJ. Disease management for chronic congestive heart
failure. J Cardiovasc Nurs 1996;11:54 – 62.
Bernabei R, Landi F, Gambassi G, et al. Randomised trial of impact of
model of integrated care and case management for older people living in
the community. Br Med J 1998;316:1348 –51.
Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge
planning and home follow-up of hospitalized elders; a randomized
clinical trial. JAMA 1999;281:613–20.
Fitzgerald JF, Smith DM, Martin DK, Freedman JA, Katz BP. A case
manager intervention to reduce readmissions. Arch Intern Med 1994;154:
1721–9.
Wagner EH. More than a case manager. Ann Intern Med 1998;129:654 – 6.
Whitlock WL, Brown A, Moore K, et al. Telemedicine improved diabetic
management. Mil Med 2000;165:579 – 84.
Weinberger M, Kirkman MS, Samsa GP, et al. A nurse-coordinated
intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life.
J Gen Intern Med 1995;10:59 – 66.
Caravalho JY, Saylor CR. Continuum of care. An evaluation of a nurse
case-managed program for children with diabetes. Pediatr Nurs 2000;26:
296 –300,328.
Humphry J, Jameson LM, Beckham S. Overcoming social and cultural
barriers to care for patients with diabetes. West J Med 1997;167:138 – 44.
Day JL, Metcalfe J, Johnson P. Benefits provided by an integrated
education and clinical diabetes centre: a follow-up study. Diabet Med
1992;9:855–9.
Giordano B, Rosenbloom AL, Heller D, Weber FT, Gonzalez R, Grgic A.
Regional services for children and youth with diabetes. Pediatrics 1977;
60:493– 8.
Lowes L. Evaluation of a paediatric diabetes specialist nurse post. Br J
Nurs 1997;6:625– 6, 628 –33.
Edelstein EL, Cesta TG. Nursing case management: an innovative model
of care for hospitalized patients with diabetes. Diabetes Educ 1993;19:
517–21.
Ginn M, Frate DA, Keys L. A community-based case management model
for hypertension and diabetes. J Miss State Med Assoc 1999;40:226 – 8.
Weinberger M, Oddone EZ, Henderson WG. Does increased access to
primary care reduce hospital readmissions? Veterans Affairs Cooperative
Study Group on Primary Care and Hospital Readmission. N Engl J Med
1996;334:1441–7.
Peters AL, Davidson MB, Ossorio RC. Management of patients with
diabetes by nurses with support of subspecialists. HMO Pract 1995;9:8 –13.
Lorber D. What works? The Diabetes Care and Information Center.
Diabet Med 1998;15(suppl 4):S24 –7.
Beyerman K. Casefinder program IDs 1,500 at risk for diabetes. Hosp Case
Manag 1999;7:204 – 6.
American Diabetes Association. American Diabetes Association: clinical practice recommendations 2001. Diabetes Care 2001;24(suppl 1):S1–S133.
Wagner EH. Care of older people with chronic illness. In: Calkins E, Boult
C, Wagner EH, Pacala JT, eds. New ways to care for older people. New
York, NY: Springer Publishing, 1998:39 – 64.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of
leading chronic disease management programs: are they consistent with
the literature? Manag Care Q 1999;7:56 – 66.
Cabana MD, Rand CS, Power NR, et al. Why don’t physicians follow
clinical practice guidelines? A framework for improvement. JAMA 1999;
282:1458 – 65.
Roos LL, Sharp SM, Cohen MM. Comparing clinical information with claims
data: some similarities and differences. J Clin Epidemiol 1991;44:881– 8.
O’Connor PJ, Rush WA, Pronk NP, Cherney LM. Identifying diabetes
mellitus or heart disease among health maintenance organization members: sensitivity, specificity, predictive value, and cost of survey and
database methods. Am J Manag Care 1998;4:335– 42.
Norris SL, Engelgau MM, Venkat Narayan KM. Effectiveness of selfmanagement training in type 2 diabetes: systematic review of randomized
controlled trials. Diabetes Care 2001;24:561– 87.
Bodenheimer T. Disease management—promises and pitfalls. N Engl
J Med 1999;340:1202–5.
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Reprinted by permission of Elsevier Science from:
The effectiveness of disease and case management for people with diabetes: a systematic
review. Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack Jr. L, Isham
GJ, Snyder SR, Carande-Kulis VG, Garfield S, Briss P, McCulloch D, Task Force on
Community Preventive Services., American Journal of Prevention Medicine. Vol 22 No 4S,
pp 15-38.